Caring for patients is not only a clinical endeavor, it is also an ethical one. Patient care and ethics are woven together as an integral part of every doctor-patient encounter. Medical schools have traditionally taught students the principle-based ethics approach of autonomy, beneficence, non-malfeasance, and justice. These abstract principles are often applied to “big” patient care situations, such as physician-assisted suicide, organ transplantation, and withholding/withdrawing treatment. The life and death areas of principle-based ethical decision-making have garnered a lot of attention over the years, but what about teaching our future physicians the ethics involved in the everyday practice of medicine?
I became acquainted with the concept of everyday ethics through the work of Dr. Solomon Papper, a general internist, who wrote and published a primer titled, “Doing Right: Everyday Medical Ethics.” In his book, Dr. Papper describes the virtuous behaviors every physician should engage in with every patient every time. He discusses the responsibilities of the physician, patient management, physician attitudes, self-discipline, and much more. The approach Dr. Papper supports is based on the personal character of the physician and his or her behaviors toward or with patients. We might consider this approach to be virtues in action, embedded in the daily practice of medicine. Most of what Dr. Papper proposes is a given, the way in which we expect to be treated when we are sick and in need of care, but it never hurts to be reminded of what is important and the positive or negative impact our behavior can have on others.
Virtue ethics inhabits the domain of ordinary, everyday events, like when a physician walks into the exam room to see a patient, or when a nurse arrives to take the patient’s vital signs and review his list of medications. Physicians can take specific actions such as calling the patient by name, making eye contact, and touching the patient in a non-threatening way to indicate empathy and acknowledgment. Doing so will help establish trust and build the relationship. These actions don’t require much time and can make a big difference in the quality of the encounter.
Imagine a female patient who comes to the clinic with chronic obstructive pulmonary disease (COPD). She has been labeled a “difficult” patient by the clinic staff. She often does not show up for her appointments and has continued to smoke even though she knows she shouldn’t. Standing outside the exam room, the doctor immediately feels irritated when he pulls the chart and sees it is this particular patient. He knows he is already behind on seeing patients and now thinks he will be even more behind. He walks in without knocking and sits down facing his computer. Without looking up, he says, “I understand you are not taking your medicines, and you have not quit smoking like I told you to.” The patient says she cannot afford her medicines, and even if she could, she has a difficult time getting to the pharmacy. She says that her daughter is in jail and has to watch her three young grandchildren until the matter is resolved. “Smoking cigarettes,” she says, “is my only pleasure.” Instead of responding with empathy, the physician tells her she needs to figure out a way to manage or she is going to die. The patient begins to cry.
This patient has a chronic illness, which will not improve unless she quits smoking and takes her medication. It is also clear there are social factors affecting her ability to follow through with the doctor’s recommendations. The skills a physician needs to deal with the whole of this patient’s illness and predicament are different from the skills he needs to treat her COPD, although we do expect the physician to be competent to treat the disease appropriately. A physician needs to respond with common decency, a sense of respect and politeness. Likewise, a discerning, conscientious, and compassionate physician can grasp and consider the entirety of the patient’s situation, not just the COPD, and be more mindful of the patient’s limitations. Physicians who exhibit the virtues of decency, discernment, conscientiousness, compassion, and competence are more likely to be considered trustworthy. An acronym for remembering these virtues is Dr. Do-good Comforts the Crying Child: decency, discernment, conscientiousness, trustworthiness, compassion, and competence.
I also learned about virtues through the work of Edmund Pellegrino. Dr. Pellegrino was a physician, scholar, and bioethicist. In an interview with the American Medical Association (AMA), Dr. Pellegrino said he was often asked what the most important thing was in the ethics of medicine, and he would reply, “…I always say it’s the character of the physician. The kind of person the physician ought to be—that’s what virtue ethics concerns itself with.” These days physicians often feel pressured by administrators to see more patients in less time, while spending the other half of their day on electronic medical record systems that may or may not work right. We already know this behavior contributes to physician burnout, but I expect it contributes to less virtuous behavior as well. It is common sense that physicians who are hungry, angry, late, tired, or overburdened with administrative tasks are less likely to be empathic with their patients.
The concept of virtues is not something we explicitly teach or rarely discuss with our learners. It was not until my own life-threatening illness that I began to fully appreciate that medical ethics cannot be taught like a biochemistry course and that teaching principle-based ethics will not counteract the values, beliefs, and attitudes that students experience as part of the hidden curriculum. A set of abstract principles would not have been helpful when I found myself lying face down on the bathroom floor consumed with fear and grief shortly after my cancer diagnosis. What I needed, and what I received, was a call from my oncologist reassuring me that I was strong and that she would be there with me no matter the final outcome. I needed a compassionate, discerning, and trustworthy physician, in addition to being a highly skilled and knowledgeable cancer doctor.
It is discouraging that the business of medicine is interfering with the art of medicine. Perhaps it is time to relook at this imbalance and get back to “doing right” in caring for patients.
Sheila Crow is a professor of pediatrics and a medical educator.
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